Application of Nursing Intervention Based on Intelligent Grip Strength System in Patients with Tumor PICC: A Case-Control Study on Promoting Functional Exercise and Quality of Life

Objective . A case-control study was conducted to elucidate the impact of application of nursing intervention based on intelligent grip strength system in patients with tumor peripherally inserted central catheter (PICC) on promoting functional exercise and life quality. Methods . A total of 100 patients with tumor PICC treated in our hospital from April 2019 to April 2021 were enrolled. The patients were randomly assigned into control group and study group. The control group received routine nursing, and the study group received nursing intervention based on intelligent grip strength system. Results . First of all, we compared the nursing satisfaction between the two groups: the study group was very satis ﬁ ed in 43 cases, satisfactory in 6 cases, and general in 1 case, and the satisfaction rate was 100.00%, while in the control group, 29 cases were very satis ﬁ ed, 10 cases were satis ﬁ ed, 6 cases were general, and 5 cases were dissatis ﬁ ed. The satisfaction rate was 90.00%. As such, the nursing satisfaction of the study group was higher compared to the control ( P < 0 : 05 ). Secondly, we compared the average blood ﬂ ow velocity per unit time of axillary vein at di ﬀ erent moments. Before catheterization, there randomized controlled studies should be carried out to explore the impact of intelligent grip strength system on the long-term e ﬀ ect of functional exercise in patients with PICC.


Introduction
Catheter-related complications are the main factors affecting the duration of peripherally inserted central catheter (PICC) [1]. According to the study, the incidence of catheter-related complications is about 20% to 35% [2,3]. Complications can occur at any time during the period of PICC catheterization, and the most common complication is deep venous thrombosis of the upper limb [2]. Catheter-related thrombosis (CRT) refers to the process of forming blood clots on the inner wall of the blood vessel or catheter due to mechanical damage employed by catheter puncture, chemical damage employed by drug stimulation, and the state of the patient after the insertion of PICC catheter [4]. Catheter-related DVT leads to an increase in mortality in patients [5]. From an anatomical viewpoint, the PICC catheter occupies most of the cross-sectional diameter of the peripheral vein of the arm, causing venous stasis, and the placement of the PICC catheter may cause mechanical damage to the vascular wall; activate platelets and coagulation systems; lead to local vascular contraction, platelet adhesion, and fibrous hyperplasia; and promote thrombosis [5]. Chemotherapeutic drugs are easy to stimulate the inner wall of blood vessels, cause the injury of vascular intima, and further affect the balance of blood coagulation and fibrinolysis; chemotherapy reactions such as nausea, vomiting, and fatigue employed by chemotherapy reduce the independent activity of patients and slow blood flow, resulting in blood stasis and thrombosis [5]. Risk factors for catheter-related thrombosis can be classified into three types: chemotherapy and the use of prophylactic anticoagulants; patient factors, such as history of trauma or surgery, tumor, history of venous thrombosis, and age and renal failure; and catheter size, type, head position, puncture point, catheterization times, and catheter indwelling time [6].
In 2008, the American Institute of Medicine (IOM) regarded venous thrombosis during hospitalization as a medical negligence, and the United States Health Care Research and Quality Management Agency believes that the provision of preventive treatment for venous thrombosis is the most important measure [7]. The prevention of PICC catheter-related thrombosis mainly includes drug prophylaxis and physical prophylaxis. Among them, drug prophylaxis is mainly the routine use of preventive dose of anticoagulant [7], and physical prevention is mainly the exercise of the arm on the side of catheterization [8]. Tumor research groups in Germany and the UK employed conventional doses of low molecular weight heparin and warfarin to prevent thrombosis, respectively, but did not achieve the desired results [9]. In addition, meta-analysis of 12 randomized controlled trials in the Cochrane database indicated that 3611 patients with catheterization using preventive dose heparin or low-dose vitamin K antagonists also failed to confirm the effect of anticoagulants in reducing the incidence of thrombosis [10].
The new practice of standard for venous therapy (INS) recommends starting upper limb exercise as early as possible after catheterization, but does not recommend detailed exercise methods [11]. In the Guide to Clinical Nursing Practice published by the Ministry of Health, the specific methods of physical prevention are not mentioned in the nursing care of patients with PICC catheterization. In "Peripheral Central Venous Catheterization Technology and Management," the education method for patients with PICC catheterization is to hold the elastic ball 3-4 times a day, 15-20 minutes a day, and do clenched fist-loosening fist movements. This is the first domestic monograph on grip strength exercise after PICC catheterization [11,12].
At present, most hospitals in China recommend the use of grip ball or electronic grip for functional exercise to prevent catheter-related complications for patients after PICC catheterization [11]. However, there are no unified norms and standards for upper limb functional exercise after PICC catheterization at home and abroad. Health education is carried out according to the standards of various hospitals, which is lack of science and safety, and nursing education is performed blindly without taking into account the individual differences of patients, resulting in the decline of patients' compliance, and the incidence of catheter-related complications is still high [12]. After consulting a great quantity of literatures at home and abroad, it is found that the main method of physical exercise is to guide patients to do clenched fist-loose fist movement, ball-loose ball movement, or upper limb movement repeatedly. When clenching the fist, there is no physical object in the patient's hand, the strength of clenching fist is difficult to master, it is easy to be diverted, and the effect of exercise is poor; the grip device is more expensive, the hospitalization cost of the patient increases, and the psychological burden is increased; the movement of the body is complex, it is difficult for the patient to accept and master, the compliance is poor, and the effect of exercise is poor. With the wide application of the Internet, the health management model based on mobile phone application software has been developed rapidly. Studies have shown that the health management model based on mobile phone application software can improve the compliance of postoperative functional exercise and promote the rehabilitation of breast cancer patients [13]. In this study, with the intelligent grip ball as the carrier, integrating the advantages of grip movement and hand functional exercise, the mobile phone application software "Intelligent grip strength system" was designed to decline the functional exercise compliance of PICC patients, promote functional exercise, improve the quality of life, and reduce the incidence of catheter-related thrombosis.

Clinical Information.
A total of 100 patients with tumor PICC treated in our hospital from April 2019 to April 2021 were enrolled. The patients were randomly assigned into control group and study group. In the control group, the age was from 26 to 78 years old with the average age (47:13 ± 3:56), including 49 males and 51 females, while in the study group, the age was from 25 to 76 years old, with the average age (47:78 ± 3:67), including 53 males and 47 females. There was no statistical significance in the general data of the two groups. This study was approved by the Medical Ethics Association of our hospital, with all patients signing informed consent.
The inclusion criteria were as follows: (1) the pathological examination was malignant tumor and needed PICC catheterization; (2) the age was more than 18 years old; (3) patients who made an appointment for catheterization in PICC clinic; (4) patients signed an informed consent form and voluntarily join this study; (5) the patient had normal hand mobility ability and could cooperate with functional exercises after surgery; and (6) the patient was clearly conscious and had no communication difficulties.
The exclusion criteria were as follows: (1) the patients with other serious organic diseases; (2) history of thrombosis and phlebitis of upper limb on the side of catheterization; (3) vascular malformation of upper limb, enlargement of axillary lymph nodes, or other conditions affecting venous reflux; and (4) history of catheterization.

Treatment
Methods. The patients in the control group received routine nursing intervention in the department, and the patients were instructed to move the arm on the side of the tube 24 hours after catheterization, and the limbs on the side of the tube employed the traditional grip strength ball to hold the ball. When gripping the ball, ask the patient to hold the power ball completely with the palm of his hand, and grasp the ball vigorously with each finger. Take the maximum grip strength that can be achieved as the standard, hold for 2 s, and then loose for 2 s. Exercise once a day in the morning, respectively, in the middle and in the evening, 10-15 min each time.
On the basis of the control group, the research group implemented the nursing intervention based on the intelligent grip strength system. The specific measures are as follows: (1) Design of the intelligent grip strength system: This study used the principle of the Internet of things to connect the smart grip strength ball to the mobile phone application software through Bluetooth. According to the characteristics of postoperative functional exercise in patients with PICC, the researchers designed the intelligent grip strength system into three modules by consulting the relevant literature and combining with the actual clinical needs. The training plan was assigned into five steps: clenching fist training, finger training, wrist training, arm training, and relaxation massage. Clench training for the patient tube side arm to use 80% of the maximum grip strength to hold the ball for 2 s and loose 2 s; finger training was that the thumb was placed at the bottom of the grip ball, and the other four fingers are gently placed in the depression of the grip ball for grip training; wrist training was to follow the picture provided on the software to rotate the wrist up and down or left and right; arm training was to bend the arm forward or on both sides of the body following the picture provided on the software. The above movements last 30 times in each group, 3 times per day, once in the morning, once at noon, and once in the evening, and the specific time can be set according to the habits and needs of patients. 15 min before the beginning of training, the intelligent grip strength system will send a reminder message, and when the patient does not train at the set time point, the system will send a message to remind the patient again. The intelligent grip strength system can record the training data of patients every day, including training time, training content, and whether the training is up to the standard. When the action meets the set standard, the intelligent grip strength system will count automatically; otherwise, it will not be counted. If the training of the patients is not up to the standard, the system will pop up a dialog box at the medical end and the guardian side of the family members to remind the medical staff and the family members of the patients to guide or supervise the patients to carry out functional exercise in time. After the above training, patients can choose the weak, medium, and strong relaxation massage. In addition to the set training plan, a somatosensory game with the intelligent grip ball as the carrier is also designed in the intelligent grip strength system to increase the interest of the training. The health education module embeds PICC content to guide patients on how to manage themselves. According to the needs of patients in different periods, relevant educational content will be pushed regularly. Q and A follow-up includes replying questions and sending notices. If patients have questions, they can leave messages and upload pictures at any time. Researchers check messages occasionally and give professional answers. (2) Before the intervention of the use of the intelligent grip strength system, the researchers asked the patients to hold the ball with the maximum grip strength, evaluate the maximum grip strength, and then set the effective grip strength value (effective grip strength = maximum grip strength × 80%) according to the maximum grip strength. Set up a training plan for each patient according to the needs of the patient. After 24 hours of catheterization, patients were instructed to use intelligent grip strength system for limb functional exercise on the side of catheterization, and every patient was taught to use intelligent grip strength ball correctly.

Observation Index
2.3.1. Satisfaction. After consulting the literature and expert discussion, we designed patients' follow-up satisfaction [14], a total of 10 items, and recorded patients' satisfaction with follow-up management mode, health education, medical and nursing service, appointment registration process and so on. It is assigned into four dimensions: very satisfied, satisfied, general, and dissatisfied. Satisfaction rate = very satisfaction rate + satisfaction rate + general rate.

Average Blood Flow Rate per Unit Time of Axillary
Vein. By the same attending physician of ultrasound department, the average blood flow velocity of axillary vein in all subjects was measured before catheterization, 14 days after catheterization and 28 days after catheterization. In the examination room where the room temperature was constant at 25°C, the patient was told to lie flat on the examination bed, remove the sleeve on the side of the tube, extend the arm 60°, and place the palm upward. During the measurement, the patients were told to hold their breath, and after obtaining the smooth waveforms of at least three cardiac cycles, the blood flow spectrum was frozen, and the average blood flow velocity per unit time of the axillary vein 3 Computational and Mathematical Methods in Medicine was measured. The measurement time was controlled within 10 seconds; during the measurement process, the patients were told to keep calm breathing, to not speak, and to not cough, so as not to affect the accuracy of the measurement results.

Incidence of Catheter-Related Complications.
Statistics of the incidence of catheter-related complications in the two groups = the number of patients with confirmed catheterrelated complications/the total number of patients × 100%, including puncture point redness and swelling, phlebitis, blockage of the tube, and external slip of the catheter.

Measurement of Vascular
Diameter, Peak Velocity of Blood Flow and Vascular Pressure. The researchers first determined the measurement location under ultrasound monitoring and marked it (2-5 cm above the aseptic film of the catheter vein). Before and after each ball holding session, the patients were measured with a portable ultrasound diagnostic instrument. The researchers walked along the blood vessels in mode B for cross-sectional display, took screenshots after freezing, and measured and recorded the diameter of blood vessels. After adjusting to PW mode and refreshing, enter the color flow Doppler mode, display the longitudinal section along the blood vessels, observe the color Doppler blood flow, freeze and capture the spectrum curve after the spectrum curve shows a stable waveform, and measure and record the blood flow velocity and vascular pressure.

Functional Exercise
Compliance. PICC patients' functional exercise compliance questionnaire was employed to evaluate patients' functional exercise compliance [15]. The questionnaire consists of 16 items, including four dimensions: grip exercise compliance, exercise monitoring compliance, active help compliance, and exercise attention compliance. Each item was scored by "impossible at all, occasionally, basically and completely," corresponding to 0: 3, and the total score was 0: 48. The higher score, the better the patients' compliance with functional exercise. The Cronbach's α coefficient of the questionnaire was 0.965, and the content validity index was 0.879. When the patients came to the hospital for vascular color ultrasound examination on the 28th day after catheterization, the researchers explained the purpose of the survey to the patients and issued the questionnaire after obtaining consent. The patient filled it out independently and then withdrew it on the spot. If there were any questions about the items of the questionnaire, it would be explained by the researcher and completed. The researcher checked on the spot before the questionnaire was collected, and if there were any missing items or errors, they would supplement and verify them in time.
2.3.6. Life Quality Scale. The life quality scale [16] consisted of four subscales, including physical, psychological, social, and health self-awareness, with a total of 29 items. The Cronbach's α coefficient of the scale is 0.79 to 0.91. The scale was scored by 1-5 grades. The lower the score, the higher satisfaction of patients.

Statistical
Analysis. SPSS 23.0 statistical software was employed to analyze the data. The measurement data in accordance with normal distribution were expressed by mean and standard deviation, and compared between groups by t test, and the counting data were expressed by frequency, percentage, or percentage. χ2 test or rank sum test was employed for comparison between groups; P < 0:05 indicated that the difference was statistically significant.

Comparison of Nursing Satisfaction.
First of all, we compared the nursing satisfaction: the study group was very satisfied in 43 cases, satisfactory in 6 cases, and general in 1 case; the satisfaction rate was 100.00%, while in the control group, 29 cases were very satisfied, 10 cases were satisfied, 6 cases were general, and 5 cases were dissatisfied. The satisfaction rate was 90.00%. Collectively, the nursing satisfaction of the study group was higher compared to the control (P < 0:05). All the results are shown in Figure 1.

Comparison of Average Blood Flow Velocity per Unit
Time of Axillary Vein at Different Time Points. Secondly, we compared the average blood flow velocity per unit time of axillary vein between the two groups at different time points; there exited no significant difference before catheterization (P > 0:05), but 14 days and 28 days after catheterization, the average blood flow velocity per unit time of axillary vein in the study group was faster compared to control (P < 0:05). All the data results are shown in Table 1.

Comparison of the Incidence of Catheter-Related
Complications. Next, we compared the incidence of catheterrelated complications. The incidence of catheter-related complications such as redness and swelling, phlebitis, catheter occlusion, and catheter slip in the study group (12.00%) was lower compared to the control (60.00%) (P < 0:05). All the data results are shown in Figure 2.

Comparison of Vascular Diameter, Peak Velocity of Blood Flow and Vascular
Pressure. Then, we compared the vascular diameter, blood flow peak velocity, and vascular pressure; there exited no significant difference before nursing (P > 0:05), but after nursing, compared to the control, the vascular diameter and peak blood flow velocity were higher, and the vascular pressure was lower in the study group (P < 0:05). All the data are shown in Table 2.

Comparison of Functional Exercise
Compliance. After, we compared the scores of functional exercise compliance. The scores of grip exercise compliance, exercise monitoring compliance, active help seeking compliance, exercise attention compliance, and the total score of compliance in the study group were significantly higher compared to the control (P < 0:05). The results of all the data are shown in Table 3.
3.6. Comparison of Life Quality Scores. Finally, we compared the scores of qualities of life. Before nursing, there exited no significant difference (P > 0:05). The scores of physiological function, psychological function, social function, and health self-cognition in the study group were lower compared to 4 Computational and Mathematical Methods in Medicine the control (P < 0:05). All the data results are shown in Table 4.

Discussion
PICC is a deep venous catheter made of silicone or polyurethane or reinforced polyurethane, marked with a clear scale.
It is capable of radiography, punctured through the basilic vein, median cubital vein, and cephalic vein. The tip of the catheter is located in the superior vena cava or at the junction of the superior vena cava and the right atrium to supply the body with liquid medicine and nutrition [17].  [19]. In the process of infusion, extravasation of chemotherapeutic drugs into the skin can lead to different degrees of tissue injury, causing serious stimulation to local skin tissue, causing upper limb redness and swelling, pain, phlebitis, and even tissue necrosis and upper limb dysfunction. The emergence of central venous catheters in the 1970s solved a big problem [20]. PICC catheter is a central venous catheter located at the head end of the superior vena cava, which protects the peripheral vein from damage and can be infused with hypertonic and irritating drugs for a long time, such as chemotherapeutic drugs, antibiotics, and total parenteral nutrition [21]. The "Technical Code of practice for intravenous Therapy and Nursing" clearly states that "PICC catheter is suitable for medium-and long-term intravenous therapy and can be employed for drug infusion of any nature" [22]. In 2016, the American Society of intravenous Infusion Nursing (INS) recommended that antineoplastic drugs should be safely administered through the central vascular pathway device and pointed out that the duration of infusion should be limited if peripheral catheters were employed to infuse blister drugs [23]. Meanwhile, it is also reported that peripheral intravenous infusion of chemotherapeutic drugs is prone to the risk of drug extravasation [24]. It is pointed out that the effective measure to reduce drug extravasation is to improve the infusion rate of central venous catheter. The placement of PICC catheter in tumor patients is mainly employed for the infusion of chemotherapeutic drugs, which can reduce the peripheral venous stimulation of chemotherapeutic drugs and help patients complete the treatment successfully [24]. With the development of medicine, the use of central venous catheter in tumor patients is increasing [25]. However, it is reported that the common complications after catheterization are catheter-related thrombosis, infection, mechanical phlebitis, repeated exudation at puncture point, skin allergy, catheter prolapse, and ectopic catheter [25]. The emergence of venous thrombosis may lead to local vascular blockage, resulting in ischemia and hypoxia, which requires long-term antithrombotic therapy, and may interrupt the original treatment process of patients, and serious cases can lead to increased morbidity and mortality. The occurrence of complications not only affects the comfort and quality of life of patients with tube, but also prolongs the hospitalization time of patients, and increases the burden of families and medical institutions [25]. Catheter-related thrombosis is a serious complication after PICC, with an incidence of 1%-4%. The incidence of tumor patients is as high as 25% [26]. Catheter-related thrombosis can lead to unplanned extubation and increase the hospitalization time and cost of patients. Therefore, the practical standard of infusion therapy recommends that PICC patients start upper limb functional exercise as early as possible to prevent catheter-related thrombosis [27]. Functional exercise is based on kinematics, neurodevelopment, and biomechanics  with the main goal of improving physical, physiological, psychological, and mental dysfunction. At the same time, it is also a positive self-treatment, through the patient's own subjective efforts, to correct various functional disabilities caused by the disease, to improve or fully recover, and to gain the ability to participate in work and social life [28]. According to the current point of view, early functional exercise after catheterization means that patients can start exercise after their physiological function is stable. After successful catheterization of tumor patients, health education is carried out by health-care workers to guide patients to carry out active and passive activities, formulate an exercise plan to encourage patients to actively participate in exercise, step by step, and persevere. In addition, functional exercise is not carried out alone, but should be carried out at the same time as the disease treatment and throughout the treatment. The mechanism of functional exercise after PICC catheterization is to squeeze muscle group, stimulate musculoskeletal contraction, enhance muscle strength, promote venous and lymphatic reflux of upper limb, improve hemodynamics, and prevent catheter-related complications. At present, nurses mainly instruct PICC patients to use the method of holding the ball or hand functional exercise to carry out upper limb functional exercise. Holding the ball is a simple and effective isometric contraction of forearm muscles, which has a significant effect on speeding up the venous blood flow of the upper limb. However, the traditional grip ball has different soft and hard degrees, the grip strength cannot be quantified, the form of exercise is single, and the exercise compliance of patients is low. At the same time, although the form of hand functional exercise is vivid and    Note: the control group before and after nursing, a P < 0:05; the study group before and after nursing, b P < 0:05.
the movements are various, the patients are easy to forget. In view of these shortcomings, the intelligent grip strength system can exert an important potential. Kalil's research pointed out that through semistructured interview with patients with different functional exercises, it is found that through routine health education, most patients could understand the importance of functional exercise, but their compliance was low during actual exercise, which may be related to complex exercise patterns, patients' lack of grasp of the strength and frequency of holding the ball, lack of active participation consciousness, and effective supervision after discharge [29]. In addition, tumor patients are often accompanied by poor appetite, fatigue, physical deficiency, and other symptoms; it is difficult to hold the ball with maximum grip strength, resulting in poor functional exercise compliance [30]. In addition, the traditional grip strength ball can not evaluate the grip strength of patients. Because the training intensity of the patients is more arbitrary and the duration of holding the ball is different, it will be difficult for the venous blood of the upper limb to be fully emptied and filled, and the ideal exercise effect can not be achieved. In order to solve these problems, when patients exercise with the intelligent grip strength system, the grip strength, standardized action guidance, and effective exercise times will be displayed on the mobile phone screen, so as to improve the effect of functional exercise. Moreover, effective functional exercise can enhance the afterload of upper arm muscle contraction, increase blood circulation and lymphatic reflux, improve local microcirculation, repair the injured venous intima, and effectively reduce the incidence of catheter-related thrombosis. The intelligent grip strength system we use in this study combines the smart grip ball with mobile phone application software through Bluetooth and has the following advantages [31]: (1) Using 80% maximum grip strength, the patients can achieve the purpose of exercise while saving physical strength (2) Through the visual exercise guidance and accurate quantification of grip strength data, the motion map provided on the software guided patients to exercise, through real-time counting, and patients can also evaluate the effectiveness of exercise.
(3) The training data is transmitted to the application software of the patient side through Bluetooth, and synchronized to the medical terminal and the family guardian side through the network. When patients exercise independently, it is convenient for nurses and patients' families to guide and supervise.
(4) Personalized functional exercise reminders can be set according to the condition of patients, and medical staff can also push corresponding self-management articles at different stages after catheterization.
(5) The interactive question-and-answer function enables patients' questions to be answered in a timely manner, and medical staff can also timely understand the situation of patients' functional exercise and urge them to carry out functional exercise. (6) The somatosensory game with the intelligent grip ball as the carrier combines exercise with the game to increase the interest of exercise so as to prevent patients from giving up because of exercise fatigue.
Taken together, the utilization of intelligent grip strength system can improve the functional exercise compliance of PICC patients, effectively facilitate the venous blood circulation of upper limbs, and enhance the quality of life, as well as reduce the incidence of catheter-related thrombosis. However, the sample size of this study is small, and the long-term effect of functional exercise is not followed up and evaluated. Thus, multicenter, large-ample, randomized controlled studies should be carried out to explore the impact of intelligent grip strength system on the long-term effect of functional exercise in patients with PICC.

Data Availability
No data were used to support this study.

Conflicts of Interest
The authors declare that they have no conflicts of interest.